This document discusses various voice disorders including dysphonia, dysarthria, dysarthrophonia, and hoarseness. It describes the main causes of voice disorders as inflammatory, neoplastic/structural, neuromuscular, and muscle tension imbalance. Treatment options discussed include vocal hygiene and lifestyle advice, voice therapy, medical treatment such as for acid reflux, phonosurgery procedures, and in some cases Botulinum toxin injections. Specific voice disorders covered in detail include vocal fold polyps, nodules, Reinke's edema, and muscle tension dysphonia.

1. Disorders of the voice
Dysphonia : any impairment of the voice or difficulty speaking.
Dysarthria : difficulty in articulating words caused by impairment of the muscles used in speech.
Dysarthrophonia : dysphonia in conjunction with dysarthria. Foe example after CVA, head injury &
motor neurone disease.
Dysphasia : impairment of the comprehension of spoken or written language (sensory dysphasia) or
impairment of the expression by speech or writing (expressive dysphasia).
Hoarseness: a perceived rough, harsh or breathy quality to the voice.
There are four main causes of voice disorders
1.inflammatory
2. neoplastic or structural
3. neuromuscular
4. muscle tension imbalance.
Treatment overview
1. Vocal hygiene, lifestyle & dietary advice.
2. Voice (speech) therapy;
3. Specialist therapy for example singing therapy;
4. Medical treatment;
5. Phonosurgery.
Vocal hygiene, lifestyle & dietary advice
It is likely that most patients with a voice disorder will benefit from advice on these issues. The areas
covered may include:
1. An explanation of how the voice works;
2. The links between lifestyle, phonatory & nonphonatory vocal activities & stress on voice
disorders;
3. The potentially traumatic effects to the vocal folds of vocally abusive behaviours, such as
talking or singing too loudly, talking too fast, shouting, throat clearing & harse coughing.
4. Communicating effectively without raising or straining the voice.(using amplification devices,
change of jobs).

2. 5. The important of adequate hydration for vocal fold function, i. E. By drinking water, use of
steam inhalations & avoiding excessive amounts of drinks containing caffeine, i.e. coffe, tea
& cola.
6. Smoking cessation, reduceing alcohol & social drug consumption (particularly spirits,
cannabis & cocaine) & avoiding exposure to fumes, dust & dry air;
7. Diet & reflux reduction, for example avoiding eating late at night, large or fatty meals.
Voice therapy
This is the mainstay of treatment for muscle tension dysphonia. The aim of voice therapy sessions
are:
1. To help the patient find a better voice quality which is stable, reliable& less effortful to
produce.
2.To make better use of vocal resonance & tonal quality;
3.To increase the flexibility of the voice by improving the pitch range & loudness without undue
effort;
4.To increase the stamina of the voice.
Various techniques are used including one or more of the following:
1. Vocal exercise with the aim of targeting & strengthening specific muscle group & improving
glottal closure & efficiency
2. Increasing awareness of & reducing excessive tension in the muscles around the larynx, neck
& shoulders;
3. Advice on posture & improving breathing during speech;
4. Laryngeal massage;
5. General relaxation exercises & stress management
6. Psychological counselling
7. Remedial singing lesion.
Medical treatment
This mainly includes treatment for acid reflex & upper respiratory tract infections & allergies.
Botulinum toxin injections into the laryngeal muscles may be used in cases of spasmodic dysphonia
& arytenoids granuloma.
Phonosurgery including medialization procedures
Phonosurgery refers to any surgery designed primarly for the maintainance, restoration or
enhancement of the voice. It includes:

3. 1. Microlaryngeal surgery: the aim is usually to remove pathological tissue & attempt to
restore the normal surface contour & layered structure of the vocal cords.
2. Laryngeal injection techniques: various synthetic, biological & autologous materials are
usually injected laterally into the muscle of deep layers with a view to augmenting the vocal
fold.
3. Laryngeal framework surgery; transcutaneous surgery performed on the cartilaginous
skeleton of larynx for example, laryngoplasty ( thyroplasty), arytenoids adduction
&cricothyroid approximation with a view to improving glottis closure & body –cover
differential tone.
4. Nerve-muscle pedicle graft techniques; used foe bulking out or restoring tone to the vocal
fold.
5. Reinnervation & electrode pacing techniques; used for restoring tone to the vocal folds or
stimulating contraction of specific muscles.
Inflammatory disorders of the larynx
Inflammation of the larynx can be broadly classified into & noninfective causes. Patients often
complain of :
1. Hoarseness of voice;
2. Reduced pitch;
3. Pitch instability;
4. An increase effort to speak;
5. Vocal fatique
6. Throat symptoms such as globus sensation, irritation, dryness, throat clearing or chronic
cough.
Laryngitis is simply indicating a variable degree erythaema, oedema, ulceration, leukoplakia&
stiffness of mucosa of the vocal fold.
Accurate diagnosis may require a diagnostic microlaryngoscopy with biopsy.
Treatment consist of reduced voice use, voice rest, vocal hygiene, lifestyle & dietary advice,
appropriate medical & surgical treatment.
Arytenoids granuloma(contact ulcer or contact granuloma, vocal process granuloma,
intubation granuloma, peptic granuloma)
Arytenoids granuloma result from injury to the thin mucoperichondrium over the vocal process from
mechanical trauma (either following intubation or repeated high velocity impact of the vocal
processes against each orher from throat clearing, coughing or talking in a habitual low pitched
,creaky, hyperfunctional manner.

4. Man tend to develop granuloma secondary to hyperfunction, while women develop more
commonly as a result of intubation. Gastro-oesophageal reflex is an aetiological factor leading to
mechanical trauma or preventing healing of damaged mucosa.
Patients present with a change of voice or vocal fatique, a constant tickling sensation, discomfort or
pain localised on posterosuperior aspect of the larynx which worse on phonation, coughing, throat
clearing, it can radiate to the ear.
Treatment
Stopping smoking
Improving vocal hygiene
Treating any RTI, allergies, GERD.
Voice therapy
Confirming the diagnosis histologically , laser vapourization arfter biopsy.
No good response to use of antibiotic or steroids.
Butolinum toxin injections into the thyroarytenoid muscle can be helpful as an adjunct treatment in
resistant cases as it reduce the impact of the vocal processes against each other allowing the
epithelium to heal.
Vocal fold polyps
A true vocal polyp is a benign swelling of greater than 3mm that arises from free edge of the
vocal fold. It is usually solitary, but can occasionally affect both vocal cords. It is claimed that polyps
are the most common structural abnormality that cause hoarseness & they affect men than
women. Commonly seen in smokers between 30& 50years.
Phonotrauma is an important aetiological factor. Some are heralded by sudden onset of hoarseness
or loss of voice after yelling or shouting if the vocals folds are inflamed from acute infective laryngitis
or extraoesophageal reflex. Disruption to the vascular basement, capillary proliferation, thrombosis,
minute haemorrhage & fibrin exudation. Although some polyps have haemorrhagic appearance,
others are more gelatinous & grey.
The distinction between nodules, polypoid nodules,polyps & localized Reinke’s oedema can be
difficult both clinically & histologically. Occasionally a sulcus, mucosal bridge or intracordal cyst is
found immediately opposite on the other vocal fold.( it is hypothesized that in these cases, the
disordered vibration & stiffness of the vocal cord makes the other vocal cord causing localized
trauma & polyp formation.
The patient complain that voice is hoarse, has lowered pitch, cuts out in speech, that they have lost
part of the range of the voice & that it is a strain to speak. Very rarely, large polyps can cause
difficulty in breathing & episodes of choking.
Polyps can shrink spontaneously or even be coughed up . Most polyps need removal under general
anaesthesia(phonosurgery).

5. Vocal fold nodules
Vocal nodules are bilateral, small swellings (less than 3mm indiameter) that develop on the
free edge of the vocal fold at approximately the mid-membranous portion. In some cases,
particularly singers, they may be smaller more pointed &white in colour reflecting a more superficial
response to trauma. They may be associated with microwebs at the anterior commissure in up to
23% of cases. They are variable in size & are characterized histologically by thickening of the
epithelium with a variable degree of underlying inflammation.
Persistent hoarseness of voice 25% in children& 6% in adults. Higher percentages are found in
teacher & singers with voice problems. In children they are common in boys & in adult, they are
common in female.
Aetiology of vocal nodules is not known but are thought to be due to voice misuse rather overuse.
Voice abuse are:
1. Forced voice production due to strain in the neck & shoulder region producing harse
quality of voice.
2. It may be precipitated by talking for prolonged periods in a lound voice(above the
background voice)
3. Repeated shouting
4. Singing above one’s natural range
5. Occasionally repeated coughing & throat clearing.
Mechanism
1. Repeated trauma of the midmembranous portions leads to localized swelling & epithelial
thichening.
2. Shearing forces may be important.
3. Whiplash hypothesis has also been proposed.
4. Psychological factors, nasal , throat, chest infections, allergies & extraoesophageal reflex are
increasing being recognised in the aetiology of vocal nodules.
Voice quality is often husky & breathy worsening with voice use & often associated with
perilaryngeal discomfort or sore throat on phonation.
Treatment
If nodules are not causing significant voice problems, they should be left alone. Aggravating factors
such as inadequate vocal fold lubrication, allergies, infections & extraoesophageal reflex, should be
treated to reduce their irritants effects.
In UK, the mainstay of treatment for persistent vocal nodules is voice therapy with aim of
modification of lifestyle & vocal behaviour, providing information & guidance on voice care,

6. producing the voice more effectively with less strain & coping strategies. These measure, voice
function may improves but nodules persist.
Most would agree that a significant number of nodules recur if surgery is performed without voice
therapy (either voice therapy either pre or postoperatively).
If surgery is performed, the aim must be precise excision of the nodule alone with no exposure or
damage to the underlying ligament.
Reinke’s oedema
Reinke’s oedema is a term used to describe the vocal folds when they become chronically &
irreversibly swollen. Others terms for the condition include:
1. Polypoidal vocal cord, polypoid degeration or polypoid hypertrophy; cordal polyposis or
polypoid corditis.
2. Chronic oedema of vocal folds;
3. Pseudomyxoma or pseudomyxomatious laryngitis
4. Smoker’s larynx.
It occurs almost exclusively in moderate to heavy smokers. Voice strain & extraoesophageal reflux
may play a part in its development. Hypothyroidism may be found as a concomitant feature in some
cases.
The epithelium shows nonspecific changes & the basement membrane layer is usually thickened. In
the reinke’s space, there are lakes of oedema, extravasated erythrocytes & thickening of the wall of
the subepithelial vessels.
Clinical features:Patient with even quite severe reinke’s may have no complaints about their voice
or problems with voice use. The most common symptoms are:
1. Deeping of the pitch of the voice with women often being mistaken for a man, particularly
on telephone.
2. Gruffiness of voice;
3. Effortful speaking
4. An inability to raise the pitch of the voice
5. Choking episodes
6. Others symptoms associated with extraoesophageal reflux.
Indirect laryngoscopy finding: the diffuse lesion of the membranous part of the vocal fold are
bilateral in 62-85% of cases,although they may be asymmetrical. Typical vocal fold are grey or
yellowish in colour with prominent superficial vessels.

7. Alternatively the oedematous fold may appear diffusely red when coexistent extraoesophageal
reflux should be suspected.
In severe cases the vocal folds looks like bags of fluid that flop up & down through the glottis with
respiration.
Histologically : may be due to hyperplasia, dysplasia or very rarely carcinoma- situ.
Treatment
1. The decision to treat a patient with reinke’s oedema depend on their symptoms, severity of
the oedema & presence of leukoplakia.
2. In most cases, conservatives measures, such as reassurance, an explanation of their
condition & vocal hygiene advice including smoking cessation should be tried initially.
3. Hypothyroidism , upper respiratory infections & allergies & extraoesophageal reflux should
be treated to reduce the throat to reduce the throat symptoms.
4. Voice therapy, if vocal hygiene issues & excessive muscle tension dysphonia.
Surgical treatment should be considered when:
1. Leucoplakia is present & a histological diagnosis is required .
2. Gross reinke’s oedema is present causing choking episodes or airway compromise.
3. Pitch elevation of the voice is the main requirement of the treatment.
The principles of surgery for reinke’s oedema include:
1. Reducing the bulk of the mucosa of the vocal fold.
2. Obtaining a straight mucosal edge,i.e. avoiding leaving small deposits of the myxomatous
material behind.
3. Avoiding damage to & exposure of the underlying ligament, thereby reducing the chances of
scarring & web formation.
Special conditions
1. Sulcus vocalis : localised invagination of the mucosa of varing depth. It also called open cyst.
Trauma to the neck of the cyst(due to vocal cords movement) would lead to it widening &
discharge its contents.
2. Mucosal bridge: may also be found in presence of sulci & epidermoid cysts.
3. A sulcus vergeture: is a unilateral or bilateral linear adherence of the epilthelium to the
underlying ligament or muscles along the membranous portion of vocal cords. Reinke’s
space exists superolaterally or inferomedially to the vergeture. They are thought to result
from a congenital failure of development of reink’s space

8. Muscle tension dysphonia or functional dysphonia
Muscle tension imbalance is one of the common cause to voice disorder. Although it is often a
diagnosis of exclusion, i.e. the vocal folds look & move normally. It is often present with
inflammatory, structural & neurological conditions as laryngeal muscles try to overcome a deficiency
in the voice-producing mechanism. For example, poor respiratory function, impairment of normal
vocal fold vibration or nasal blockage affecting resonance.
Muscle tension dysphonia is a group of conditions characterized by an imbalance of the synergist
&antagonist muscles affecting vocal fold position & tensioning relative to one another , also the
position of the larynx relative to the rest of the vocal tract.
It is now thought that the previously described hypofunctional states are either end stages of
hyperfunctional laryngeal acitivity or represent an underlying paresis. The hypothesis are:
1. That chronic imbalance of muscle pull, for example of the cricothyroid muscle can lead to
irreversible joint damage & ligament stretching giving a flaccid bowel appearance to the vocal
folds.
2. That a viral neuropathic paresis has developed causing hypotrophy of the thyroarytenoid
muscle.
True hypofunction cases do exists in neurological conditions such as myasthenia gravis,
parkinsonism, motor neuron disease.
There are multiple primary aetiologies of MTD including:
1. Stress, anxiety & depression
2. Conversion disorders;
3. Postural & breathing problems;
4. Poor vocal hygiene
5. Talking in poor acoustic environments or background noise for prolonged periods at work or
socially.
6. Exposure to excessive environmental dust,smoke or fumes.
Clinical features
The degree of dysphonia is variable ranging from an intermittent problem related to a particular task
for example, teaching.
Others symptoms include:
1. Pitch of voice may be too high or too low.
2. A sensation of tightness, constriction or lump in the throat;
3. Effortless voice production;

9. 4. Discomfort on speaking or singing;
5. Vocal fatique.
Treatment
1. Vocal hygiene, dietary & life style;
2. Voice therapy targeted at specific muscle groups.
3. Laryngeal manipulation;
4. Behavioural therapy;
5. Medical treatment for example of extraoesophageal reflux.

10. 4. Discomfort on speaking or singing;
5. Vocal fatique.
Treatment
1. Vocal hygiene, dietary & life style;
2. Voice therapy targeted at specific muscle groups.
3. Laryngeal manipulation;
4. Behavioural therapy;
5. Medical treatment for example of extraoesophageal reflux.